Types of Pain Relief for Labor

There are several useful methods to relieve pain during labor and delivery.

PREPARED CHILDBIRTH OR LAMAZE TECHNIQUES
These relaxation and breathing techniques are designed to help you manage the discomfort of labor and delivery. They are best learned and practiced in childbirth education classes before your due date.

INTRAVENOUS PAIN MEDICATIONS
Intravenous (I.V.) pain medications are used mainly in early labor and usually are prescribed by your obstetrician. Although they may not provide total relief, these medications can significantly reduce pain with few side effects to you and your baby.

LOCAL ANESTHESIA
Local Anesthetics may be used by your obstetrician at the time of delivery to numb the vaginal and rectal areas. Local anesthesia often is used when an episiotomy is necessary. While local anesthesia may ease the pain of the delivery itself, it will not ease the pain of labor.

REGIONAL ANESTHESIA
Regional Anesthesia includes spinal and epidural anesthesia. Regional blocks are administered by injection of an anesthetic solution into the lower back to ease the pain of labor or for anesthesia during a cesarean section.

What is PCEA?
PCEA, more commonly called a "patient controlled epidural analgesia," or simply an "epidural", is one of many options for pain control (analgesia) during labor. It is achieved by injecting pain medicine directly into the epidural space of the lower back via a small plastic tube. This epidural catheter is typically left in place so that additional medication can be administered for as long as you are in labor. Once you have delivered, it is removed. PCEA is generally considered one of the most effective methods for patients wishing for pain relief but wanting to be awake and able to participate in the birth. “Patient controlled” means that you help decide what level of pain relief you require.


What is the difference between a spinal and an epidural?
Although they are very similar means of administering pain medication, a spinal and an epidural have important differences that dictate when and why they should be used. Because the epidural's catheter allows for a continuous infusion of analgesic over time, this procedure is typically chosen for pain relief during the course of labor.

A spinal however, usually involves a single, one-time dose of anesthetic, which is injected beyond the epidural space into the fluid –filled spinal canal. Whereas an epidural takes effect gradually over a 10-15 minute period, and lasts throughout labor, a spinal takes effect almost immediately but is shorter acting. There is one type of spinal, called a saddle block that can be used just before the delivery of your baby for effective short-term pain relief.

If I have had other pain medication during labor, can I still get an epidural?
Yes. It is very common to have received intravenous or intramuscular pain medication before an epidural.

Are there physical or medical conditions that would prevent someone from getting a labor epidural?
Yes. Underlying back problems like spina bifida or spina bifida occulta are absolute contraindications to an epidural. Previous lower back surgery and severe scoliosis can make placement of epidural more complicated and, in some cases, impossible.

Other contraindications for epidural include; brain tumors or conditions that cause an increase in intracranial pressure, infection at the intended puncture site, allergies to a specific class of local anesthetics, certain blood thinner medications (excluding aspirin or ibuprofen-like drugs), and certain medical conditions that prevent your blood from clotting properly. Chronic back pain, progressive neurological diseases (for example multiple sclerosis),blood infection, and preexisting neurological deficits in your back or legs could also be contraindications to an epidural. Your anesthesiologist will take your significant medical history and will answer any questions you have about specific medical problems and PCEA.

Is there a "window of opportunity" for getting an epidural or can I get one any time?
The "window of opportunity" depends mostly on your obstetrician, family doctor, or nurse midwife. In general, if you already have your mind set on wanting an epidural for pain control, it makes sense to place it as soon as a regular active labor pattern is established. Even if the labor pain is still tolerable at this point, once the PCEA is in place and you become more uncomfortable, it is fairly easy to dose the catheter appropriately to your comfort. If you are unsure whether you want PCEA or not, you can wait and see how you feel with progression of labor. Most often catheters are placed before your cervix is more than 6 cm dilated.

However, even in the late stages of cervical dilation, especially if this is your first baby and the actual pushing phase of labor may take longer than in subsequent deliveries, it is possible to place an epidural.

Does it hurt when placing an epidural?
Most patients do not experience significant discomfort during the insertion of epidural catheters. After cleansing the skin, a local anesthetic is injected to numb the area where the epidural will go. Local anesthetics such as this ordinarily will give a stinging or burning sensation during injection. For the average patient, this is the most uncomfortable part of the procedure, and is of only a few seconds' duration.

After the local, the actual insertion of the epidural needle is typically limited to sensations of pressure or pushing, and by some gritty, popping sensations as the needle is advanced through the tissues. These sensations are entirely normal to feel and should not serve as cause for alarm. Any discomfort during this phase is usually limited to a mild ache and easily tolerated by most patients. Of course, every individual has different tolerances to pain and some persons seem to have more discomfort during the procedure than others. Usually the injection of the local with its momentary burning sensation is the worst part.

How soon will it work?
When you have been prepared for your epidural, the anesthesiologist will be notified and will come as soon as he or she is able. After a brief screening interview, you will be positioned either on your side or sitting according to the preference of the anesthesiologist. The procedure for inserting the epidural will then begin. For patients with normal anatomy, this usually takes only a matter of minutes, but if the patient has an abnormality of the spine or is significantly overweight the procedure can become technically difficult and may take longer to complete. Once the epidural catheter has been successfully placed the initial dose of anesthetic medication is injected and pain relief generally ensues within five or ten minutes. Our usual practice is to begin with an initial injection and continue with an infusion of anesthetic solution that is aimed at providing continuous pain relief throughout the remainder of the patient's labor. Most patients attain adequate control of their labor pain with this technique. Sometimes, during labor, a patient will experience the return of labor pains at some later time. Most often this can be relieved by the patient activating the pump to give additional small doses of anesthetic solution; this is the “patient controlled” part of the process. Occasionally it becomes necessary to replace the epidural catheter if it appears to have become dislodged and is no longer delivering the medication to the right place.

What kind of relief can I expect from a labor epidural?
A labor epidural is designed to give you relief from the pain caused by your contractions and the pain of delivering your baby, as it moves through the birth canal. Once the epidural takes effect, a few contractions after insertion, most women describe their contractions as "pressure" sensations rather than pain.

At times, the PCEA may be more effective on one side of your body than the other. Some women may have a "hot spot," which is an area, usually on one side of your lower abdomen that is not completely comfortable. Usually, additional small doses of local anesthetic or short-acting narcotic drug delivered via the epidural catheter will improve these areas of discomfort.

There are times though, when, for no apparent reason, a "perfectly good" PCEA does not provide effective pain relief. This may occur in up to 10- 20% of patients. In rare instances the epidural catheter may work itself out of the epidural space and need to be replaced.

Can an epidural affect my ability to push?
Under certain circumstances, pushing may not be as effective. Concerns about the effect of PCEA on pushing ability, prolongation of labor, instrument-assisted vaginal delivery, and rates of Cesarean section now appear unfounded.

The circumstances which most practitioners agree to that may affect your ability to push are: if the medication makes you too comfortable so that you can't feel your contractions at all, it may be hard to coordinate your pushing efforts with your contractions. If too much local anesthetic is administered, your pelvic and abdominal muscles may become somewhat weakened, and less effective at pushing. These are the reasons why the effectiveness and the degree of anesthesia from PCEA are frequently reassessed throughout labor, and why we try to maintain that “urge” to push at the appropriate time.

What are the potential side effects and complications for me from an epidural?
The techniques for administering epidural anesthesia that have been developed have a good track record for safety in the laboring patient. In our practice, we do thousands of labor epidurals each year, and it is uncommon for patients to encounter serious complications from them.

The most common side effect is the transient soreness you may feel in your back where the epidural was placed. This is similar to the discomfort you may have from the IV needle in your arm. The epidural procedure itself is done in a sterile fashion and the infection rate is extremely low. Any significant bleeding from an epidural is very rare.

PCEA often causes a small transient drop in blood pressure, which is normal. This occurs because the nerves that control the diameter of the blood vessels are blocked at the same time as the nerves carrying pain sensations.

If your blood pressure changes too much, you may start to feel dizzy or nauseated. This is infrequent; your blood pressure will be monitored closely during the procedure. IV fluid is given in advance of the placement of an epidural and medications may be given to you if your blood pressure decreases significantly. Other measures such as supplemental oxygen for the mother and positioning the mother on her side (alleviating potential compression of the major blood vessels by the pregnant uterus) are also taken. When this complication occurs, such corrective actions are nearly always effective. There have, however, been isolated cases in which the administration of an epidural and subsequent blood pressure decrease was followed by a drop in the baby's heart rate that did not recover with therapy, precipitating an emergency C- Section.

There is a 1-3% incidence of what's often called a "spinal headache" after an epidural. A spinal headache usually occurs the next day and it worsens whenever you try to sit up or stand. Most spinal headaches get better on their own or can be treated with ibuprofen, intravenous fluids, and caffeine. Infrequently, some patients with severe or persistent headache may require an "epidural blood patch", in which a small amount of the patient's own blood is injected through an epidural needle into the epidural space.

Up to 15% of women may develop a low-grade fever during labor. The reason for this is unclear but may be related to dehydration. The temperature elevation is not associated with an increased risk of infection in both the mother and the child.

Allergic reactions to local anesthetics or the narcotic used for PCEA are rare (less than 1%). Sometimes the narcotic in the medication can cause you to have itching. At times, women become dizzy or feel like they are passing out when the epidural is placed because of hyperventilation with contractions or nervousness about the procedure. The best protection from this reaction is proper communication between you, your nurse, and your anesthesiologist.

Extremely rare complications are:

• Too much of the local anesthetic is accidentally injected into a blood vessel. You may feel lightheaded, develop a seizure, (incidence less than 1 in 9.000) or have problems with heart rhythm irregularities(incidence less than 1 in 10.000). This is why your anesthesiologist is very careful when injecting the medication and why he/she only injects small amounts at a time.
  
  
• The local anesthetic goes into the spinal space instead of the epidural space and you may have an" accidental spinal block". If this is not recognized, breathing problems may develop from a high spinal block. Again, this is an extremely rare complication (incidence less than 1 in 8000).
  
  
• Nerve injuries after an epidural are extremely rare and have not been reported at MJH (less than 1 in 40.000 to 1 in 200.000 in large studies). Transient nerve injuries after vaginal delivery are likely due to the birthing process itself. Nerve injury in this setting can be caused from pressure by the fetal head on the nerves that course through the pelvis en route to the legs, or sometimes by stretching of nerves if the legs are held back during pushing. In patients with epidurals, these types of nerve injury are usually not recognized until after discontinuation of the epidural, when persistent numbness or weakness is noted. Fortunately, most patients rebound from this without developing permanent problems.

Selected References:
1. Welcome to pain free childbirth - Labor epidural anesthesia
2. Epidural Pain Relief During Labor Does Not Increase Chance of Cesarean Delivery

Types of Anesthesia for Cesarean Sections